- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $933.25 / $3,467.37 / $4,365.16
| Facility | | $933.25 | $3,467.37 | $4,365.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,318.26 / $2,398.83 / $3,981.07
| Professional | | $1,318.26 | $2,398.83 | $3,981.07 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,238.72 / $2,691.53 / $3,162.28
| Professional | | $2,238.72 | $2,691.53 | $3,162.28 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $489.78 / $812.83 / $2,884.03
| Facility | | $489.78 | $812.83 | $2,884.03 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $562.34 / $2,818.38 / $5,370.32
| Professional | | $562.34 | $2,818.38 | $5,370.32 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,174.90 / $5,754.40
| Facility | | $371.54 | $1,174.90 | $5,754.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,737.80 / $2,344.23 / $3,630.78
| Professional | | $1,737.80 | $2,344.23 | $3,630.78 |